The danger of free surface water, in this case in the fish hold, is that it causes a considerable reduction in the stability of a vessel, particularly when combined with the effects of the heavy loads stowed high up (nets, jet skis and a skiff on deck). The negative effect of free surface water on the vessel's stability was not realized by anyone on board. The effect of this combination of forces was a reduction in the vessel's ability to return to the upright when upsetting moments caused her to heel. Such upsetting moments may have been created by the wind and tide in opposition, particularly in areas of tide rips. The Sailing Directions for the area make frequent reference to the rough seas which can be experienced when an ebb tide flows against the prevailing westerly winds. They make particular reference to the dangers to small craft in the vicinity of Ripple Point, where tide rips commonly develop and near which the COURAGEOUS capsized. At the time of the occurrence, the ebb current was peaking and was being opposed by the wind. Steering may be difficult in these conditions; however, the vessel was being steered by a novice seaman when she became caught in a tide rip and lost directional stability. Speed was not reduced before the vessel listed to starboard and capsized. On smaller fishing vessels, it is common for the sleeping area to be in the forecastle. Because it is below deck level, the forecastle is very difficult to access and exit, especially in darkness. Newly built vessels and those undergoing major conversions in the United States are required to have two means of escape from the forecastle area. There are similar provisions in the Canadian regulations. The COURAGEOUS had only one narrow staircase leading up to the galley from the engine-room and the forecastle sleeping area, and consequently, only one means of escape from both of these spaces. As an existing vessel, she was not required to have two exits from the forecastle area. Further, as a Fishery Coastwise Vessel under 200GRT, she was not subject to inspection by the USCG. As the vessel listed to starboard and capsized, the crew member who had been asleep on the starboard bunk (and later lost his life), may have become disoriented in the dark and unable to escape from the accommodation. The hydrostatic releases fitted to the vessel's liferaft and EPIRB are designed to automatically release the life-saving appliances to which they are connected when the vessel is sinking. According to Safety of Life at Sea Convention (SOLAS) requirements, the hydrostatic release is supposed to operate before a depth of four metres is attained. After the vessel capsized, the hydrostatic release on the liferaft functioned, but only partially because it fouled the senhouse slip which connects the strap to the release. Had the hydrostatic release been submerged to a greater depth, a larger hydrostatic force would have been encountered and the release would have been freed through the senhouse slip. Since the occurrence, the manufacturers of the hydrostatic release have modified the hydrostatic release to free it through the senhouse slip at the much lower hydrostatic pressure of 62.05kPa (9psi) as opposed to the 137.89kPa (20psi) force required prior to the modifications.Analysis The danger of free surface water, in this case in the fish hold, is that it causes a considerable reduction in the stability of a vessel, particularly when combined with the effects of the heavy loads stowed high up (nets, jet skis and a skiff on deck). The negative effect of free surface water on the vessel's stability was not realized by anyone on board. The effect of this combination of forces was a reduction in the vessel's ability to return to the upright when upsetting moments caused her to heel. Such upsetting moments may have been created by the wind and tide in opposition, particularly in areas of tide rips. The Sailing Directions for the area make frequent reference to the rough seas which can be experienced when an ebb tide flows against the prevailing westerly winds. They make particular reference to the dangers to small craft in the vicinity of Ripple Point, where tide rips commonly develop and near which the COURAGEOUS capsized. At the time of the occurrence, the ebb current was peaking and was being opposed by the wind. Steering may be difficult in these conditions; however, the vessel was being steered by a novice seaman when she became caught in a tide rip and lost directional stability. Speed was not reduced before the vessel listed to starboard and capsized. On smaller fishing vessels, it is common for the sleeping area to be in the forecastle. Because it is below deck level, the forecastle is very difficult to access and exit, especially in darkness. Newly built vessels and those undergoing major conversions in the United States are required to have two means of escape from the forecastle area. There are similar provisions in the Canadian regulations. The COURAGEOUS had only one narrow staircase leading up to the galley from the engine-room and the forecastle sleeping area, and consequently, only one means of escape from both of these spaces. As an existing vessel, she was not required to have two exits from the forecastle area. Further, as a Fishery Coastwise Vessel under 200GRT, she was not subject to inspection by the USCG. As the vessel listed to starboard and capsized, the crew member who had been asleep on the starboard bunk (and later lost his life), may have become disoriented in the dark and unable to escape from the accommodation. The hydrostatic releases fitted to the vessel's liferaft and EPIRB are designed to automatically release the life-saving appliances to which they are connected when the vessel is sinking. According to Safety of Life at Sea Convention (SOLAS) requirements, the hydrostatic release is supposed to operate before a depth of four metres is attained. After the vessel capsized, the hydrostatic release on the liferaft functioned, but only partially because it fouled the senhouse slip which connects the strap to the release. Had the hydrostatic release been submerged to a greater depth, a larger hydrostatic force would have been encountered and the release would have been freed through the senhouse slip. Since the occurrence, the manufacturers of the hydrostatic release have modified the hydrostatic release to free it through the senhouse slip at the much lower hydrostatic pressure of 62.05kPa (9psi) as opposed to the 137.89kPa (20psi) force required prior to the modifications. The vessel was laden with nets both in the hold and on deck, and had a seine skiff and jet skis on deck. The fish hold had been drained of ballast water, but it was reported that there was some water remaining in the hold thereby creating a free surface effect. The vessel did not have any stability calculations, although some alterations had been made to the vessel's structure in the recent past. At the time of capsizing, the vessel was being steered by a novice seaman under the supervision of an experienced deck-hand. The vessel capsized close to Edith Point in Johnstone Strait when the ebb tide was peaking and the wind was opposing the tide, possibly creating tide rips. The only means of escape from the forecastle sleeping area to the galley was by one narrow staircase. Five crew members, who escaped and clung to the capsized vessel, were rescued. A sixth crew member was trapped in the forecastle sleeping area and did not escape. His body was recovered later.Findings The vessel was laden with nets both in the hold and on deck, and had a seine skiff and jet skis on deck. The fish hold had been drained of ballast water, but it was reported that there was some water remaining in the hold thereby creating a free surface effect. The vessel did not have any stability calculations, although some alterations had been made to the vessel's structure in the recent past. At the time of capsizing, the vessel was being steered by a novice seaman under the supervision of an experienced deck-hand. The vessel capsized close to Edith Point in Johnstone Strait when the ebb tide was peaking and the wind was opposing the tide, possibly creating tide rips. The only means of escape from the forecastle sleeping area to the galley was by one narrow staircase. Five crew members, who escaped and clung to the capsized vessel, were rescued. A sixth crew member was trapped in the forecastle sleeping area and did not escape. His body was recovered later. The COURAGEOUS capsized because marginal positive stability was lost while transiting an area affected by tide rips. The strong ebb tide with an opposing wind and an inexperienced seaman at the helm contributed to the accident. Following the occurrence, TSB Marine Safety Information Letter No.7/95 was forwarded to the USCG concerning the potentially unsafe stability condition of the COURAGEOUS due to structural modifications. In addition, TCMarine Safety was apprised, via TSB Marine Safety Advisory No.6/95, of the design modification made to improve the hydrostatic release mechanism for liferafts, similar to that of the COURAGEOUS, which had failed during the accident.Causes and Contributing Factors The COURAGEOUS capsized because marginal positive stability was lost while transiting an area affected by tide rips. The strong ebb tide with an opposing wind and an inexperienced seaman at the helm contributed to the accident. Following the occurrence, TSB Marine Safety Information Letter No.7/95 was forwarded to the USCG concerning the potentially unsafe stability condition of the COURAGEOUS due to structural modifications. In addition, TCMarine Safety was apprised, via TSB Marine Safety Advisory No.6/95, of the design modification made to improve the hydrostatic release mechanism for liferafts, similar to that of the COURAGEOUS, which had failed during the accident.